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Zaveri PG, Walker AM, Upadhyay K, Talati AJ. Use of Vasopressors in Extremely Preterm Infants in First Week of Life. Am J Perinatol 2023; 40:513-518. [PMID: 33990125 DOI: 10.1055/s-0041-1729558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE A significant variability exists for diagnosis and treatment of hypotension in extremely preterm infants. Benefits of the use of vasopressors remain unclear. We wanted to identify the risk factors associated with use of vasopressors in the first week of life and their impact on outcomes of extremely preterm infants. STUDY DESIGN Retrospective review of all newborns ≤28 weeks of gestational age (GA) admitted in neonatal intensive care unit from October 1, 2012, to October 31, 2015, done. Data regarding antenatal and neonatal characteristics and outcomes were recorded. Study infants were divided into two cohorts and compared based on vasopressor use. Chi-square, t-test, and multiple logistic regression were performed as appropriate and significance set at p <0.05. RESULTS Of 213 extremely preterm infants, 90 (42.3%) received vasopressors in first week of life. The mean arterial pressure (MAP) at admission in these infants was significantly lower than that of infants who did not require vasopressors (27 ± 8 vs. 30 ± 6 mm Hg, p < 0.05). Vasopressors were initiated within 24 hours in 91% of babies. After controlling for other variables, use of vasopressors was significantly higher in infants with lower birth weight (odds ratio [OR]: 3.2, 95% confidence interval [CI]: 1.6-8.3), 5-minute Apgar's score ≤5 (OR: 1.8, 95% CI: 1.2-3.12), and admission hypothermia (OR: 2.7, 95% CI: 1.3-4.9). The use of vasopressors was significantly associated with severe intraventricular hemorrhage (IVH), even after controlling for other significant variables (OR: 5.9, 95% CI: 1.6-9.3). CONCLUSION Lower birth weight, low 5-minute Apgar's score, and admission hypothermia are characteristics associated with early use of vasopressors in extremely preterm infants. Infants treated with vasopressors are at a higher risk of developing severe IVH. KEY POINTS · Low systemic blood pressure is a very common problem in the extremely preterm population.. · In clinical practice, mean arterial blood pressure (BP) less than the infants GA in week is typically considered to be "low BP.". · About 50% of infants born at <29 weeks of GA received very preterm in the first week of life.. · Use of vasopressors is associated with a higher incidence of intraventricular hemorrhage in extremely preterm population..
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Affiliation(s)
- Parul G Zaveri
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
- Division of Neonatology, Regional One Health, Memphis, Tennessee
| | - Amanda M Walker
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kirtikumar Upadhyay
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Ajay J Talati
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
- Division of Neonatology, Regional One Health, Memphis, Tennessee
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Wolfsberger CH, Hoeller N, Suppan E, Schwaberger B, Urlesberger B, Nakstad B, Pichler G. Peripheral fractional oxygen extraction measured with near-infrared spectroscopy in neonates-A systematic qualitative review. Front Pediatr 2022; 10:940915. [PMID: 36081622 PMCID: PMC9445360 DOI: 10.3389/fped.2022.940915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Peripheral fractional oxygen extraction (pFOE) measured with near-infrared spectroscopy (NIRS) in combination with venous occlusion is of increasing interest in term and preterm neonates. OBJECTIVE The aim was to perform a systematic qualitative review of literature on the clinical use of pFOE in term and preterm neonates and on the changes in pFOE values over time. METHODS A systematic search of PubMed, Embase and Medline was performed using following terms: newborn, infant, neonate, preterm, term, near-infrared spectroscopy, NIRS, oximetry, spectroscopy, tissue, muscle, peripheral, arm, calf, pFOE, OE, oxygen extraction, fractional oxygen extraction, peripheral perfusion and peripheral oxygenation. Additional articles were identified by manual search of cited references. Only studies in human neonates were included. RESULTS Nineteen studies were identified describing pFOE measured with NIRS in combination with venous occlusion. Nine studies described pFOE measured on the forearm and calf at different time points after birth, both in stable preterm and term neonates without medical/respiratory support or any pathological findings. Nine studies described pFOE measured at different time points in sick preterm and term neonates presenting with signs of infection/inflammation, anemia, arterial hypotension, patent ductus arteriosus, asphyxia or prenatal tobacco exposure. One study described pFOE both, in neonates with and without pathological findings. CONCLUSION This systematic review demonstrates that pFOE may provide additional insight into peripheral perfusion and oxygenation, as well as into disturbances of microcirculation caused by centralization in preterm and term neonates with different pathological findings. SYSTEMATIC REVIEW REGISTRATION [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021249235].
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Affiliation(s)
- Christina H Wolfsberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Hoeller
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Ena Suppan
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Britt Nakstad
- Division of Pediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pediatric and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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3
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Dempsey EM, Barrington KJ, Marlow N, O'Donnell CPF, Miletin J, Naulaers G, Cheung PY, Corcoran JD, EL-Khuffash AF, Boylan GB, Livingstone V, Pons G, Macko J, Van Laere D, Wiedermannova H, Straňák Z. Hypotension in Preterm Infants (HIP) randomised trial. Arch Dis Child Fetal Neonatal Ed 2021; 106:398-403. [PMID: 33627329 PMCID: PMC8237176 DOI: 10.1136/archdischild-2020-320241] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/02/2020] [Accepted: 12/06/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To determine whether restricting the use of inotrope after diagnosis of low blood pressure (BP) in the first 72 hours of life affects survival without significant brain injury at 36 weeks of postmenstrual age (PMA) in infants born before 28 weeks of gestation. DESIGN Double-blind, placebo-controlled randomised trial. Caregivers were masked to group assignment. SETTING 10 sites across Europe and Canada. PARTICIPANTS Infants born before 28 weeks of gestation were eligible if they had an invasive mean BP less than their gestational age that persisted for ≥15 min in the first 72 hours of life and a cerebral ultrasound free of significant (≥ grade 3) intraventricular haemorrhage. INTERVENTION Participants were randomly assigned to saline bolus followed by either a dopamine infusion (standard management) or placebo (5% dextrose) infusion (restrictive management). PRIMARY OUTCOME Survival to 36 weeks of PMA without severe brain injury. RESULTS The trial terminated early due to significant enrolment issues (7.7% of planned recruitment). 58 infants were enrolled between February 2015 and September 2017. The two groups were well matched for baseline variables. In the standard group, 18/29 (62%) achieved the primary outcome compared with 20/29 (69%) in the restrictive group (p=0.58). Additional treatments for low BP were used less frequently in the standard arm (11/29 (38%) vs 19/29 (66%), p=0.038). CONCLUSION Though this study lacked power, we did not detect major differences in clinical outcomes between standard or restrictive approach to treatment. These results will inform future studies in this area. TRIAL REGISTRATION NUMBER NCT01482559, EudraCT 2010-023988-17.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Keith J Barrington
- Néonatologie, Centre Hospitalier Universitaire Sainte Justine, Montreal, Quebec, Canada
| | - Neil Marlow
- Institute for Womens Health, University College London, London, UK
| | | | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Gunnar Naulaers
- Neonatology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - John David Corcoran
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif Faisal EL-Khuffash
- Faculty of Medicine and Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Geraldine B Boylan
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Vicki Livingstone
- Department of Paediatric and Child Health and INFANT Research Centre, University College Cork, Cork, Ireland
| | - Gerard Pons
- Clinical Pharmacology, Groupe Hospitalier Cochin-Broca, Hôtel Dieu, AP-HP, Paris, France
| | - Jozef Macko
- Department of Neonatology, Tomas Bata University in Zlin, Zlin, Zlínský Kraj, Czech Republic
| | | | - Hana Wiedermannova
- Department of Pediatrics and Neonatal Care, Ostravska Univerzita, Ostrava, Moravskoslezský, Czech Republic
| | - Zbyněk Straňák
- Institute for the Care of Mother and Child, Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Barrington K, El-Khuffash A, Dempsey E. Intervention and Outcome for Neonatal Hypotension. Clin Perinatol 2020; 47:563-574. [PMID: 32713451 DOI: 10.1016/j.clp.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Many observational studies have shown that infants with blood pressures (BPs) that are in the lower range for their gestational age tend to have increased complications such as an increased rate of significant intraventricular hemorrhage and adverse long-term outcome. This relationship does not prove causation nor should it create an indication for treatment. However, many continue to intervene with medication for low BP on the assumption that an increase in BP will result in improved outcome. Only adequately powered prospective randomized controlled trials can answer the question of whether individual treatments of low BP are beneficial.
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Affiliation(s)
| | - Afif El-Khuffash
- The Rotunda Hospital, Dublin and Royal College of Surgeons, Dublin, Ireland
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Ireland.
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5
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Bandyopadhyay T, Saili A, Yadav DK, Kumar A. Correlation of functional echocardiography and clinical parameters in term neonates with shock. J Neonatal Perinatal Med 2019; 13:167-173. [PMID: 31744019 DOI: 10.3233/npm-180179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To evaluate the correlation between functional echocardiography and clinical parameters in term neonates with shock. METHOD Cross sectional study of 30 full term newborns who were clinically detected to have shock compared to 30 full term hemodynamically stable neonates. For statistical analysis, cases were further sub classified into cardiogenic and septic shock. RESULT Functional echocardiography revealed inferior vena cava collapsibility index (cIVC), fractional shortening (FS), ejection fraction (EF), cardiac output and superior vena cava (SVC) flow were significantly lower whereas myocardial performance index (MPI) was significantly higher in babies with cardiogenic and septic shock as compared to the controls. Left ventricular end diastolic area (LVEDA) was significantly higher in cardiogenic shock whereas it was significantly lower in septic shock as compared to the controls. Also, cIVC was significantly lower and LVEDA was significantly higher in cardiogenic as compared to the septic shock. In cardiogenic shock SVC flow correlated significantly with capillary filling time and systolic blood pressure. The correlation between functional echocardiographic parameters of cardiogenic and septic shock showed that EF, FS and MPI were positively and significantly correlated (r 0.742, p 0.022 for EF, r 0.766, p 0.016 for FS and r 0.478, p 0.05 for MPI) whereas SVC flow and cIVC were negatively and significantly correlated between cardiogenic and septic shock (r - 0.655, p 0.045 for SVC flow and - 0.578, p 0.05 for cIVC). CONCLUSION In the complex environment of neonatal intensive care unit detection of shock continues to be a major challenge. Functional echocardiography provides an adjunct information to the clinical assessment of shock and helps in monitoring the response to treatment.
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Affiliation(s)
- T Bandyopadhyay
- Department of Neonatology, PGIMER and Dr. RML Hospital, New Delhi, India
| | - A Saili
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
| | - D K Yadav
- Department of Pediatrics, Division of Pediatric Cardiology, PGIMER and Dr. RML Hospital, New Delhi, India
| | - A Kumar
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
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6
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Abstract
Hemodynamic instability is frequent in high-risk infants admitted to neonatal intensive care units. However, monitoring and treatment strategies of those conditions might show variations among the units. Different factors can compromise hemodynamic status in preterm/ term infants. Treatment options mostly include volume replacement, inotropes and/or vasopressors (dopamine, dobutamine, epinephrine and milrinone) and hydrocortisone. In general, these treatments are driven by predetermined protocols, which are not patient-based. According to the current knowledge, a physiology-driven approach that takes the individual characteristics of the newborn into consideration is accepted to be more suitable. In neonatal hemodynamics, important determinants are cardiac output, systemic vascular resistance, blood pressure, regional tissue perfusion and oxygenation. The novel technological methods, "targeted neonatal echocardiography" and "near-infrared spectroscopy" can help to delineate the underlying pathophysiology better, when added to the clinical assessment. In this review, strategies for the assessment of neonatal hemodynamics, as well as etiology, monitoring, and treatment of hemodynamic instability in preterm and term infants are presented.
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Affiliation(s)
- Dilek Dilli
- Department of Neonatology, University of Health Sciences, Dr. Sami Ulus Maternity and Children's Training and Research Hospital, Ankara, Turkey
| | - Hanifi Soylu
- Division of Neonatology, Department of Pediatrics, Selçuk University, Faculty of Medicine, Konya, Turkey
| | - Neslihan Tekin
- Division of Neonatology, Department of Pediatrics, Eskişehir Osmangazi University, Faculty of Medicine, Eskişehir, Turkey
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7
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Hypotension within 1 week of life associated with poor short- and long-term outcomes in very low birth weight infants. Cardiol Young 2018; 28:1037-1041. [PMID: 29962357 DOI: 10.1017/s1047951118000732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We examined whether hypotension in very low birth weight infants aged⩽1 week was associated with hospital morbidities and overall mortality. Further, we studied whether hypotension was associated with poor neurodevelopmental outcomes in these patients at the corrected age of 18 months. A total of 166 very low birth weight infants were studied during this period. Hospital outcomes and neurodevelopmental outcomes at the corrected age of 18 months were evaluated. Among the 166 very low birth weight infants, 95 patients (57.2%) experienced hypotension at⩽1 week and were associated with an increased incidence of morbidities and mortality. At the corrected age of 18 months, hypotension of the⩽1 week group had significantly lower scores in all three - cognitive, language, and motor - composites of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) screening tests. In addition, a multivariable logistic regression analysis showed that longer mechanical ventilation and periventricular leukomalacia were additionally associated with worse cognitive and language neurodevelopmental outcomes. Hypotension in very low birth weight infants within 1 week of life was associated with increased morbidities and overall mortality. It was also associated with an increased risk of cognitive and language outcomes.
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8
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Pichler G, Höller N, Baik-Schneditz N, Schwaberger B, Mileder L, Stadler J, Avian A, Pansy J, Urlesberger B. Avoiding Arterial Hypotension in Preterm Neonates (AHIP)-A Single Center Randomised Controlled Study Investigating Simultaneous Near Infrared Spectroscopy Measurements of Cerebral and Peripheral Regional Tissue Oxygenation and Dedicated Interventions. Front Pediatr 2018; 6:15. [PMID: 29450194 PMCID: PMC5799241 DOI: 10.3389/fped.2018.00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 01/16/2018] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Up to 50% of preterm infants admitted to intensive care units require cardiocirculatory support. The aim of the present study was to assess whether simultaneous monitoring of cerebral tissue oxygenation index (cTOI) and peripheral tissue oxygenation index (pTOI) using near-infrared spectroscopy (NIRS) in combination with dedicated intervention guidelines may help avoiding arterial hypotension and catecholamine administration in preterm neonates. STUDY DESIGN Preterm neonates <37 weeks of gestation were included in a single center randomized controlled study. Blood pressure was measured non-invasively or invasively. In the NIRS group, simultaneous cTOI and pTOI monitoring was used starting within 6 h after birth for 24 h to calculate changes in cTOI/pTOI ratio over time. Depending on these changes, interventions including echocardiography, administration of volume or patent ductus arteriosus treatment were performed. In the control group, only routine monitoring and treatment were performed and NIRS signals were not visible. The primary outcome was burden of hypotension within 48 h after initiation of NIRS monitoring. RESULTS 49 preterm neonates were included in each group: NIRS group 33.1 (32.0-34.0) (median: 25-75 centile) weeks of gestation and control group 33.4 (32.3-34.3) weeks of gestation. In the NIRS group, echocardiography was performed in 17 preterm neonates due to NIRS measurements, whereby six neonates received further treatment. Percentage of neonates with any hypotensive episode during the 48-h observational period was 32.6% in the NIRS group and 44.9% in the control group (p = 0.214). Burden of hypotension (i.e., %mmHg of mean arterial pressure < gestational age) was 0.0 (0.0-2.1) mmHg h in the NIRS group and 0.4 (0.0-3.3) mmHg h in the control group (p = 0.313), with observed burden of hypotension being low in both groups. No severe adverse reactions were observed. CONCLUSION In preterm neonates using simultaneous peripheral and cerebral NIRS measurements for early detection of centralization followed by predefined interventions led to a non-significant reduction in burden of arterial hypotension. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier: NCT01910467.
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Affiliation(s)
- Gerhard Pichler
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nina Höller
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Lukas Mileder
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Stadler
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Jasmin Pansy
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Research Unit for Neonatal Micro- and Macrocirculation, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Dempsey EM, El-Khuffash AF. Objective cardiovascular assessment in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2018; 103:F72-F77. [PMID: 29127152 DOI: 10.1136/archdischild-2017-313837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/11/2017] [Accepted: 10/18/2017] [Indexed: 11/04/2022]
Abstract
Traditionally, cardiovascular well-being was essentially based on whether the mean blood pressure was above or below a certain value. However, this singular crude method of assessment provides limited insight into overall cardiovascular well-being. Echocardiography has become increasingly used and incorporated into clinical care. New objective modality assessments of cardiovascular status continue to evolve and are being evaluated and incorporated into clinical care. In this review article, we will discuss some of the recent advances in objective assessment of cardiovascular well-being, including the concept of multimodal monitoring. Sophisticated haemodynamic monitoring systems are being developed, including mechanisms of data acquisition and analysis. Their incorporation into clinical care represents an exciting next stage in the management of the infant with cardiovascular compromise.
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Affiliation(s)
- Eugene M Dempsey
- Department of Paediatrics and Child Health, Neonatal Intensive Care Unit, University College Cork, Cork, Ireland.,INFANT, Irish Centre for Fetal and Neonatal Translational Research, University College Cork, Cork, Ireland
| | - Afif Faisal El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland.,Department of Paediatrics, School of Medicine, The Royal College of Surgeons in Ireland, Dublin, Ireland
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10
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Azhibekov T, Noori S, Soleymani S, Seri I. Transitional cardiovascular physiology and comprehensive hemodynamic monitoring in the neonate: relevance to research and clinical care. Semin Fetal Neonatal Med 2014; 19:45-53. [PMID: 24555196 DOI: 10.1016/j.siny.2013.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A thorough understanding of developmental cardiovascular physiology is essential for early recognition of cardiovascular compromise, selective screening of at-risk groups of neonates, and individualized management using pathophysiology-targeted interventions. Although we have gained a better understanding of the physiology and pathophysiology of postnatal cardiovascular transition over the past decade with the use of sophisticated methods to study neonatal hemodynamics, most aspects of neonatal hemodynamics remain incompletely understood. In addition, targeted therapeutic interventions of neonatal hemodynamic compromise have not been shown to improve mortality and clinically relevant outcomes. However, the recent development of comprehensive hemodynamic monitoring systems capable of non-invasive, continuous and simultaneous bedside assessment of cardiac output, organ blood flow, microcirculation, and tissue oxygen delivery has made sophisticated analysis of the obtained physiologic data possible and has created new research opportunities with the potential of direct implications to patient care.
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11
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Lightburn MH, Gauss CH, Williams DK, Kaiser JR. Observational study of cerebral hemodynamics during dopamine treatment in hypotensive ELBW infants on the first day of life. J Perinatol 2013; 33:698-702. [PMID: 23619374 PMCID: PMC3735635 DOI: 10.1038/jp.2013.44] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/10/2013] [Accepted: 03/21/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate cerebral hemodynamics during dopamine treatment in hypotensive (mean arterial blood pressure (MABP)<gestational age) extremely low birth weight (ELBW) infants. STUDY DESIGN Continuous monitoring of cerebral blood flow velocity (CBFv), MABP and PCO2 was performed in hypotensive ELBW infants on the first day of life, beginning with an ∼15-min baseline reading and continued during advancing dopamine infusion until MABP was optimized. Physiological variables and CBFv reactivity were compared before and after MABP was optimized. RESULT Fifteen hypotensive ELBW infants (625±174 g; 24 (23 to 24.8) weeks) were studied. Mean CBFv increased from 10.9±3.7 to 15.7±5.7 cm s(-1) (P=0.001) simultaneously as MABP increased from 22.3±2.8 to 35.2±9.7 mm Hg (P<0.001). Mean CBFv reactivity (95% confidence interval (CI)) was 3.9 (1.6 to 6.2) %mm Hg(-1). Nine infants died and/or developed severe intraventricular hemorrhage (IVH). CONCLUSION Mean CBFv increased pressure-passively as MABP was optimized by dopamine treatment in very sick hypotensive ELBW infants on the first day of life.
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Affiliation(s)
- Marla H. Lightburn
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - C. Heath Gauss
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - D. Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - Jeffrey R. Kaiser
- Departments of Pediatrics and Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030
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12
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Chang YS, Park WS. Strategies to Overcome the Limit of Viability of Microprimie. NEONATAL MEDICINE 2013. [DOI: 10.5385/nm.2013.20.3.258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Ahn SY, Kim ES, Kim JK, Shin JH, Sung SI, Jung JM, Chang YS, Park WS. Permissive hypotension in extremely low birth weight infants (≤1000 gm). Yonsei Med J 2012; 53:765-71. [PMID: 22665344 PMCID: PMC3381492 DOI: 10.3349/ymj.2012.53.4.765] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE We performed this study to evaluate the safety of permissive hypotension management in extremely low birth weight infants (ELBWIs). MATERIALS AND METHODS Medical records of all inborn ELBWIs admitted to Samsung Medical Center from January 2004 to December 2008 were reviewed retrospectively. Of a total of 261 ELBWIs, 47 (18%) required treatment for hypotension (group T), 110 (42%) remained normotensive (group N), and 104 (40%) experienced more than one episode of hypotension without treatment (group P) during the first 72 hours of life. Treatment of hypotension included inotropic support and/or fluid loading. RESULTS Birth weight and Apgar scores were significantly lower in the T group than the other two groups. In the N group, the rate of pathologically confirmed maternal chorioamnionitis was significantly higher than other two groups, and the rate was higher in the P group than the T group. After adjusting for covariate factors, no significant differences in mortality and major morbidities were found between the N and P groups. However, the mortality rate and the incidence of intraventricular hemorrhage (≥stage 3) and bronchopulmonary dysplasia (≥moderate) were significantly higher in the T group than the other two groups. Long term neurodevelopmental outcomes were not significantly different between the N and P groups. CONCLUSION Close observation of hypotensive ELBWIs who showed good clinical perfusion signs without intervention allowed to avoid unnecessary medications and resulted in good neurological outcomes.
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Affiliation(s)
- So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Sun Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Kyu Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hee Shin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Mi Jung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Continuous, reliable and real-time assessment of major determinants of cardiovascular function in preterm and term neonates has long been an elusive aim in neonatal medicine. Accordingly, aside from continuous assessment of heart rate, blood pressure and arterial oxygen saturation, bedside monitoring of major determinants of cardiovascular function of significant clinical relevance such as cardiac output, systemic vascular resistance, organ blood flow distribution and tissue oxygen delivery and coupling has only recently become available. Without obtaining reliable information on the changes in and interactions among these parameters in the neonatal patient population during postnatal transition and later in the neonatal period, development of effective and less harmful treatment approaches to cardiovascular compromise is not possible. This paper briefly reviews the recent advances in our understanding of developmental cardiovascular physiology and discusses the methods of bedside assessment of cardiovascular function in general and organ perfusion, tissue oxygen delivery and brain function in particular in preterm and term neonates. The importance of real-time data collection and the need for meticulous validation of the methods recently introduced in the assessment of neonatal cardiovascular function such as echocardiography, electrical impedance cardiometry, near infrared spectroscopy, visible light and laser-Doppler technology are emphasized. A clear understanding of the accuracy, feasibility, reliability and limitations of these methods through thorough validation will result in the most appropriate usage of these methods in clinical research and patient care.
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Ting JY, Cheung PY. Cerebral blood flow velocities in extremely low birth weight infants. J Pediatr 2009; 155:944; author reply 944-5. [PMID: 19914439 DOI: 10.1016/j.jpeds.2009.06.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 06/25/2009] [Indexed: 10/20/2022]
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16
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Systemic and cerebral hemodynamics during the transitional period after premature birth. Clin Perinatol 2009; 36:723-36, v. [PMID: 19944832 DOI: 10.1016/j.clp.2009.07.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Little is known about the effect on clinically relevant outcomes of the complex hemodynamic changes occurring during adaptation to extrauterine life in preterm neonates, particularly in very low birth weight neonates. As cardiovascular adaptation in this extremely vulnerable patient population is complicated by immaturity of all organ systems, especially that of the cardiorespiratory, central nervous, and endocrine systems, maladaptation has been suspected, but not necessarily proven, to contribute to mortality and long-term morbidities. This article describes recent advances in the understanding of hemodynamic changes in very low birth weight neonates during postnatal transition, and reviews the complex and developmentally regulated interaction between systemic and cerebral hemodynamics and the effect of this interaction on clinically relevant outcomes.
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O’Leary H, Gregas MC, Limperopoulos C, Zaretskaya I, Bassan H, Soul JS, Di Salvo DN, du Plessis AJ. Elevated cerebral pressure passivity is associated with prematurity-related intracranial hemorrhage. Pediatrics 2009; 124:302-9. [PMID: 19564313 PMCID: PMC4030537 DOI: 10.1542/peds.2008-2004] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Cerebral pressure passivity is common in sick premature infants and may predispose to germinal matrix/intraventricular hemorrhage (GM/IVH), a lesion with potentially serious consequences. We studied the association between the magnitude of cerebral pressure passivity and GM/IVH. PATIENTS AND METHODS We enrolled infants <32 weeks' gestational age with indwelling mean arterial pressure (MAP) monitoring and excluded infants with known congenital syndromes or antenatal brain injury. We recorded continuous MAP and cerebral near-infrared spectroscopy hemoglobin difference (HbD) signals at 2 Hz for up to 12 hours/day and up to 5 days. Coherence and transfer function analysis between MAP and HbD signals was performed in 3 frequency bands (0.05-0.25, 0.25-0.5, and 0.5-1.0 Hz). Using MAP-HbD gain and clinical variables (including chorioamnionitis, Apgar scores, gestational age, birth weight, neonatal sepsis, and Score for Neonatal Acute Physiology II), we built a logistic regression model that best predicts cranial ultrasound abnormalities. RESULTS In 88 infants (median gestational age: 26 weeks [range 23-30 weeks]), early cranial ultrasound showed GM/IVH in 31 (37%) and parenchymal echodensities in 10 (12%) infants; late cranial ultrasound showed parenchymal abnormalities in 19 (30%) infants. Low-frequency MAP-HbD gain (highest quartile mean) was significantly associated with early GM/IVH but not other ultrasound findings. The most parsimonious model associated with early GM/IVH included only gestational age and MAP-HbD gain. CONCLUSIONS This novel cerebrovascular monitoring technique allows quantification of cerebral pressure passivity as MAP-HbD gain in premature infants. High MAP-HbD gain is significantly associated with GM/IVH. Precise temporal and causal relationship between MAP-HbD gain and GM/IVH awaits further study.
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Affiliation(s)
- Heather O’Leary
- Fetal-Neonatal Neurology Research Group, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Matthew C. Gregas
- Clinical Research Program, and Children’s Hospital Boston, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Catherine Limperopoulos
- Fetal-Neonatal Neurology Research Group, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, Department of Neurology and Neurosurgery and School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Irina Zaretskaya
- Fetal-Neonatal Neurology Research Group, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Haim Bassan
- Fetal-Neonatal Neurology Research Group, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Janet S. Soul
- Fetal-Neonatal Neurology Research Group, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Donald N. Di Salvo
- Department of Radiology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Adré J. du Plessis
- Fetal-Neonatal Neurology Research Group, Department of Neurology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
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18
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Lightburn MH, Gauss CH, Williams DK, Kaiser JR. Cerebral blood flow velocities in extremely low birth weight infants with hypotension and infants with normal blood pressure. J Pediatr 2009; 154:824-8. [PMID: 19324371 PMCID: PMC2768562 DOI: 10.1016/j.jpeds.2009.01.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Revised: 12/08/2008] [Accepted: 01/06/2009] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine whether extremely low birth weight (ELBW) infants with hypotension have similar cerebral hemodynamics when compared with control subjects with normal blood pressure. We hypothesized that ELBW infants with low or normal blood pressure have similar cerebral blood flow (CBF) velocity. STUDY DESIGN In this case control study, CBF velocity (with Doppler ultrasound scanning), PCO2, and mean arterial blood pressure (MABP) were continuously monitored twice daily before intensive care procedures. If an infant became hypotensive (MABP < or = gestational age in weeks), additional monitoring was performed for 10 to 20 minutes, before treatment with dopamine. Thirty ELBW infants were enrolled (637 +/- 140 g, 24.2 +/- 1.1 weeks); 15 had hypotension, and 15 were gestational age/birth weight-matched control subjects with normal blood pressure. CBF velocity was compared by use of the Mann-Whitney U test. RESULTS The groups did not differ significantly in gestational age, birth weight, race, sex, PCO2, Apgar scores, or occurrence of severe intraventricular hemorrhage. There was no difference in mean CBF velocity (P = .934) in infants with hypotension (MABP: 23 [20-24.9] mm Hg) compared with infants with normal blood pressure (MABP: 32.6 [27.5-35.7] mm Hg). CONCLUSION Despite having hypotension, ELBW infants (before treatment) had similar CBF velocity compared with control subjects with normal blood pressure. On the basis of these results, hypotension may not indicate decreased CBF.
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Affiliation(s)
- Marla H. Lightburn
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - C. Heath Gauss
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - D. Keith Williams
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - Jeffrey R. Kaiser
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR 72205,Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR 72205
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19
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Jobe AH. Lung recruitment for ventilation: does it work, and is it safe? J Pediatr 2009; 154:635-6. [PMID: 19364555 PMCID: PMC2716052 DOI: 10.1016/j.jpeds.2009.01.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 01/21/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Alan H. Jobe
- Cincinnati Children's Hospital, Division of Pulmonary Biology, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3039
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20
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Dempsey EM, Barrington KJ. Evaluation and treatment of hypotension in the preterm infant. Clin Perinatol 2009; 36:75-85. [PMID: 19161866 DOI: 10.1016/j.clp.2008.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A large proportion of very preterm infants receive treatment for hypotension. The definition of hypotension is unclear, and, currently, there is no evidence that treating it improves outcomes or, indeed, which treatment to choose among the available alternatives. Assessment of circulatory adequacy of the preterm infant requires a careful clinical assessment and may also require ancillary investigations. The most commonly used interventions, fluid boluses and dopamine, are problematic: fluid boluses are statistically associated with worse clinical outcomes and may not even increase blood pressure, whereas dopamine increases blood pressure mostly by causing vasoconstriction and may decrease perfusion. For neither intervention is there any reliable data showing clinical benefit. Prospective trials of intervention for hypotension and circulatory compromise are urgently required.
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Affiliation(s)
- E M Dempsey
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
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21
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Abstract
Neonatology encompasses the care of all infants: from term newborns to extremely premature infants, from healthy infants to those suffering from severe infections or genetic disorders. While the management of infants can vary greatly, there are essential core data and knowledge that is needed to care for them.
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22
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du Plessis AJ. Cerebrovascular injury in premature infants: current understanding and challenges for future prevention. Clin Perinatol 2008; 35:609-41, v. [PMID: 19026331 DOI: 10.1016/j.clp.2008.07.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cerebrovascular insults are a leading cause of brain injury in premature infants, contributing to the high prevalence of motor, cognitive, and behavioral deficits. Understanding the complex pathways linking circulatory immaturity to brain injury in premature infants remains incomplete. These mechanisms are significantly different from those causing injury in the mature brain. The gaps in knowledge of normal and disturbed cerebral vasoregulation need to be addressed. This article reviews current understanding of cerebral perfusion, in the sick premature infant in particular, and discusses challenges that lie ahead.
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Affiliation(s)
- Adré J du Plessis
- Department of Neurology, Children's Hospital Boston, Boston, MA 02115, USA.
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23
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Abstract
Between 16% and 98% of extremely preterm infants receive treatment for hypotension in the first few days of life. This enormous variation has arisen because of a lack of reliable information to create an evidence base for intervention. This review article provides the unique characteristics of the neonatal cardiovascular system, and addresses the definitions of hypotension and shock in the preterm infant, the indications for treatment and appropriate therapies in individual cases. The treatment of shock and hypotension in the preterm infant may be the area of neonatology where there is the greatest 'intervention/data imbalance'; more babies receive more treatments with less supportive evidence than in virtually any other domain. Treatment of hypotension in infants with good perfusion is probably unnecessary and may be harmful, but the assessment of adequate perfusion remains problematic. Infants with inadequate oxygen delivery to the tissues may benefit from treatment, but which treatments are effective are unknown. It is essential that better evidence be available to create a rational basis for intervention.
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Affiliation(s)
- Keith J Barrington
- McGill University, NICU, Royal Victoria Hospital, 687 Pine Ave W, Montréal, Québec H3A 1A1, Canada.
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24
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Limperopoulos C, Bassan H, Kalish LA, Ringer SA, Eichenwald EC, Walter G, Moore M, Vanasse M, DiSalvo DN, Soul JS, Volpe JJ, du Plessis AJ. Current definitions of hypotension do not predict abnormal cranial ultrasound findings in preterm infants. Pediatrics 2007; 120:966-77. [PMID: 17974733 DOI: 10.1542/peds.2007-0075] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Hypotension is a commonly treated complication of prematurity, although definitions and management guidelines vary widely. Our goal was to examine the relationship between current definitions of hypotension and early abnormal cranial ultrasound findings. METHODS We prospectively measured mean arterial pressure in 84 infants who were < or = 30 weeks' gestational age and had umbilical arterial catheters in the first 3 days of life. Sequential 5-minute epochs of continuous mean arterial pressure recordings were assigned a mean value and a coefficient of variation. We applied to our data 3 definitions of hypotension in current clinical use and derived a hypotensive index for each definition. We examined the association between these definitions of hypotension and abnormal cranial ultrasound findings between days 5 and 10. In addition, we evaluated the effect of illness severity (Score for Neonatal Acute Physiology II) on cranial ultrasound findings. RESULTS Acquired lesions as shown on cranial ultrasound, present in 34 (40%) infants, were not predicted by any of the standard definitions of hypotension or by mean arterial pressure variability. With hypotension defined as mean arterial pressure < 10th percentile (< 33 mmHg) for our overall cohort, mean value for mean arterial pressure and hypotensive index predicted abnormal ultrasound findings but only in infants who were > or = 27 weeks' gestational age and those with lower illness severity scores. CONCLUSIONS Hypotension as diagnosed by currently applied thresholds for preterm infants is not associated with brain injury on early cranial ultrasounds. Blood pressure management directed at these population-based thresholds alone may not prevent brain injury in this vulnerable population.
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Affiliation(s)
- Catherine Limperopoulos
- Department of Neurology, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA
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25
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Osborn DA, Evans N, Kluckow M, Bowen JR, Rieger I. Low superior vena cava flow and effect of inotropes on neurodevelopment to 3 years in preterm infants. Pediatrics 2007; 120:372-80. [PMID: 17671064 DOI: 10.1542/peds.2006-3398] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to report the 1- and 3-year outcomes of preterm infants with low systemic blood flow in the first day and the effect of dobutamine versus dopamine for treatment of low systemic blood flow. METHODS A cohort of 128 infants born at <30 weeks of gestation underwent echocardiographic measurement of superior vena cava flow at 3, 10, and 24 hours of age. Forty-two infants with low superior vena cava flow (<41 mL/kg per minute) were assigned randomly to dobutamine or dopamine. Surviving infants underwent blinded neurodevelopmental assessments at corrected ages of 1 and 3 years. RESULTS Seventy-six of 87 surviving infants were seen at 1 year and 67 at 3 years. Forty-four infants had low superior vena cava flow. At 3 years, with adjustment for perinatal risk factors, death was predicted by low superior vena cava flow, lower gestational age, and low 5-minute Apgar score. Substantial reductions in the Griffiths General Quotient were associated with low superior vena cava flow and birth weight of <10th percentile. Infants with low flow had significant reductions in personal-social, hearing and speech, and performance subscales. Death or disability at 3 years was predicted by low superior vena cava flow and lower gestational age. For infants treated with inotropes, no significant differences were found in clinical outcomes, except for reduced rates of late severe periventricular/intraventricular hemorrhage in the dobutamine group. At 3 years, infants in the dopamine group had significantly more disability and a lower Griffiths General Quotient. At the latest time measured, however, combined rates of death or disability were similar. CONCLUSIONS Early low superior vena cava flow was associated with substantial rates of death, morbidity, and developmental impairments. No difference was found in combined rates of death and disability for infants assigned randomly to dopamine or dobutamine.
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Affiliation(s)
- David A Osborn
- Royal Prince Alfred Newborn Care, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia.
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26
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Seri I. Cardiovascular support in the preterm: treatments in search of indications. J Pediatr 2007; 150:e31-3; author reply e33. [PMID: 17236880 DOI: 10.1016/j.jpeds.2006.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 09/07/2006] [Indexed: 10/23/2022]
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27
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Giacoia GP, Mattison DR. Selected Proceedings of the NICHD/FDA newborn drug development initiative: Part II. Clin Ther 2007; 28:1337-41. [PMID: 17062307 DOI: 10.1016/j.clinthera.2006.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND In February 2003, the National Institute of Child Health and Human Development (NICHD) and the US Food and Drug Administration (FDA) created the Newborn Drug Development Initiative (NDDI), an ongoing program to determine gaps in knowledge in neonatal therapeutics and to explore clinical study designs for use in the newborn population. Working groups were established in 3 therapeutic areas: the central nervous, pulmonary, and cardiovascular systems. Three additional groups discussed pain control, drug prioritization, and ethics in neonatal clinical trials. OBJECTIVE The purpose of this article was to provide an overview of the 5 articles written by members of the Neurology, Cardiology, Drug Prioritization, and Ethics Groups. METHODS Information for the current article, as well as the 5 articles presented in this supplemental section, was gathered from the proceedings of a workshop cosponsored by the NICHD and the FDA. This workshop took place March 29 and 30, 2004, in Baltimore, Maryland. RESULTS The Neurology Group addressed the treatment of 2 common and interrelated conditions in the newborn population: neonatal seizures and hypoxic-ischemic encephalopathy. The unsubstantiated clinical preference for using phenobarbital to treat neonatal seizures, coupled with the development of several newer antiepileptic drugs with application in children, dictates the need for rigorous clinical trials of these drugs in the neonatal population. A number of pharmacologic agents currently undergoing extensive investigations in experimental animals and adult humans may have application in the newborn population. The Cardiology Group reviewed controversial approaches to the diagnosis and treatment of cardiovascular instability of preterm infants and identified gaps in knowledge. The group discussed issues of study design and developed 2 study proposals: (1) a placebo-controlled trial with a rescue arm for symptomatic infants; and (2) a targeted blood pressure (BP) trial. The Drug Prioritization Group focused on the fact that the uniqueness of the newborn population is due to distinctive and changing physiologic characteristics, conditions, and diseases that are different from those affecting older children, as well as the large differences in developmental patterns between 23 weeks of gestation and term. All of these factors help explain the lack of adequate trials and the sparseness of evidence regarding efficacy and toxicity risks of most drugs used in the newborn population. Unfortunately, the frequency of drug use and polypharmacy is highest in very-low-birth-weight infants. The large number of drugs requiring study and the uniqueness of the indications for those drugs preclude the use of the prioritization process used in older children. The focus of the Drug Prioritization Group was the determination of factors that identify which drugs are most important for study. The Ethics Group was unique in that its members were integrated into the therapeutic groups. This approach allowed for the identification of similarities and dissimilarities in the proposed clinical trial design framework. The summary report included here identifies common themes voiced in the various NDDI reports and deliberations. CONCLUSIONS The 5 articles included in this issue address different issues but share common themes: the need to develop innovative trial designs and biomarkers of efficacy, consideration of ethical concerns, and selection of appropriate drugs for study.
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Affiliation(s)
- George P Giacoia
- Obstetric and Pediatric Pharmacology Branch, Center for Research for Mothers and Children, National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland 20847, USA.
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